What is the starting dose of esmolol and how should it be ordered in a patient's chart?

Esmolol Starting Dose and Chart Ordering

Administer a loading dose of 500 mcg/kg IV over 1 minute, followed immediately by a maintenance infusion starting at 50 mcg/kg/min. 1, 2, 3

Loading Dose Protocol

• Calculate the loading dose based on actual body weight: 500 mcg/kg (0.5 mg/kg) 1, 2
• Administer over 1 minute via IV push or rapid infusion 1, 2, 3
• For immediate control in intraoperative/postoperative settings, a higher loading dose of 1 mg/kg over 30 seconds may be used, followed by 150 mcg/kg/min infusion 3

Maintenance Infusion

• Start at 50 mcg/kg/min (0.05 mg/kg/min) immediately after the loading dose 1, 2, 3
• If inadequate response after 4 minutes, repeat the 500 mcg/kg loading bolus over 1 minute and increase maintenance to 100 mcg/kg/min 1, 2, 3
• Continue this step-wise approach with repeat boluses and 50 mcg/kg/min incremental increases every 4 minutes until desired heart rate is achieved 1, 3
• Maximum recommended maintenance dose is 200 mcg/kg/min for tachycardia control—doses above this provide minimal additional benefit and increase adverse effects 1, 3
• For hypertension control specifically, higher doses of 250-300 mcg/kg/min may be required, though safety above 300 mcg/kg/min has not been established 3

How to Order in the Chart

Sample Order:

• "Esmolol 500 mcg/kg IV loading dose over 1 minute, followed by continuous infusion at 50 mcg/kg/min. Titrate by 50 mcg/kg/min increments every 4-5 minutes (with repeat 500 mcg/kg boluses) to target heart rate <100 bpm. Maximum infusion rate 200 mcg/kg/min."

Alternative simplified order for standard 70 kg patient:

• "Esmolol 35 mg IV over 1 minute, then start infusion at 3.5 mg/min (210 mg/hour). Titrate by 3.5 mg/min increments every 4-5 minutes to target HR <100 bpm. Max rate 14 mg/min (840 mg/hour)."

Critical Contraindications to Verify Before Ordering

• AV block greater than first degree or SA node dysfunction without pacemaker 1
• Decompensated systolic heart failure, cardiogenic shock, or hypotension 1
• Reactive airway disease or severe asthma 1
• Pre-excitation syndromes (WPW) with atrial fibrillation 1
• Concurrent use with other AV nodal blocking agents requires caution 1

Required Monitoring

• Continuous cardiac monitoring is mandatory 2
• Frequent blood pressure checks during titration—hypotension occurs in 20-50% of patients 3, 4
• Monitor for symptomatic hypotension (diaphoresis, dizziness)—occurs in approximately 12% of patients 3
• Watch for bradycardia—a common adverse effect requiring dose adjustment 1, 2

Key Clinical Advantages

• Onset of action within 2-5 minutes, with 90% of steady-state effect achieved within 5 minutes 4, 5
• Full recovery from beta-blockade occurs 18-30 minutes after stopping infusion 4, 5
• Elimination half-life of only 9 minutes allows rapid titration and quick reversal if adverse effects occur 6, 4, 5
• Hypotension resolves rapidly with dose reduction or discontinuation, typically within 30 minutes 3, 4

Common Pitfalls to Avoid

• Never administer without continuous cardiac monitoring 2
• Do not use in decompensated heart failure—this significantly increases risk of cardiogenic shock 1
• Avoid doses above 200 mcg/kg/min for rate control—adverse effects increase without additional benefit 1, 3
• Do not mix with sodium bicarbonate or furosemide—incompatibility causes precipitation 3
• If hypotension develops, decrease infusion rate by 50% or temporarily discontinue rather than adding vasopressors initially 3, 4